Advantages of brick-and-mortar DMEs/Hybrid mask

[roster]

I called Apria today and asked them to send me replacement cushions and pillows for the Hybrid mask that they sent me in August 2006. The Customer Service Rep gave me the news and then the branch manager called me back to confirm it. "Apria corporate" has discontinued the Hybrid mask; they will no longer sell it and do not know how to get spare parts for the ones they have already sold; something about the reimbursement.

I checked Cigna's web site and they have added some approved DMEs, so later this week I will be telephone shopping!

Sheesh!

[mattman]

As much as it sucks for folks like you who have one, I can't say I'm totally supprised.

I know we agonize over which interfaces to carry and which not to. Even more so over when to finally stop carrying a line.

Then add in the problem with trying to decide if we want to go through bringing in all new masks or even vendors every time something new comes out.

Eventually it reaches a point where we just have to say 'No' to bringing in product. I know right now we have dozens of masks that were the 'Hot' one to have, only to suddenly go cold and no one wants them and now I've got hundreds of dollars worth of merchandise sitting there doing nothing for me.

It's definately one area where I'm really jealous of online vendors who don't have to worry about it.

mattman

[neversleeps]

Wow! So, nationwide, Apria is no longer carrying the Hybrid? Did they say why?

[johnnygoodman]

Greetings,

Word recently came to us that the Hybrid is now coded under E1399 which is insurance for "misc" and by extension "do not pay". This means that while Teleflex works it out, companies like Apria and BillMyInsurance.com can not receive reimbursement for the mask and will not put it out.

In my very personal and subjective opinion, this is another situation where medical innovation is punished instead of rewarded by insurance companies. As you go through your medical travels and think "this makes no sense", most likely buried underneath is all is an insurance policy or code change.

Rooster, I don't think any DME that is aware of the code change will give you the hybrid. If you find one that is unaware and have them give you one, you are basically handing them a write off of a few hundred bucks. Someone wiser than me can sort out the moral high ground on that one.

Mattman, all this time and I didn't know you are a DME! Have you registered with our sleep service locator? Have you seen any patients yet due to it?

Johnny

[sleepingBear]

I thought that with Cigna insurance you could only use Apria. Did that change with the new year? Any idea if they will accept cpap.com now?

[neversleeps]

Is it because the folks in charge of HCPCS can't decide whether to classify it as a full face mask or a nasal mask? You'd think they'd code it as one or the other while the details are worked out instead of making it miscellaneous (hence non-payable). Seems like that would make more sense, but then, what do I know...

[mattman]

You'd think they'd code it as one or the other while the details are worked out instead of making it miscellaneous (hence non-payable). Seems like that would make more sense, but then, what do I know...

For what it's worth - E1399 doesn't mean non-payable. It's just that, a catch-all code for anything that doesn't exactly fit into any catagories OR has been deemed normally non-covered. It DOES mean a great deal more work; i.e. documentation, Medical Reviews etc.

To hit it closer to home, for example, it's how we get APAPs covered (When they are covered).

A lot of custom wheelchair accessories get billed E1399, several repiratory items and oddball things like Cam or Knee walkers etc.

mattman

[neversleeps]

For what it's worth - E1399 doesn't mean non-payable. It's just that, a catch-all code for anything that doesn't exactly fit into any catagories OR has been deemed normally non-covered.

Oops. My bad. I was going by what Johnny wrote:

Word recently came to us that the Hybrid is now coded under E1399 which is insurance for "misc" and by extension "do not pay".

To hit it closer to home, for example, it's how we get APAPs covered (When they are covered).

I thought APAPs and CPAPs used the same code.

[Guest]

That sucks.

I thought that the Hybrid would be classified as a fullface interface. Is that not what it is????

I think the insurance comanies need to get on the ball with what is what.

Many people whlo use the Hybrid use it because they are using it as a fullface mask.

I am using mine as a fullface mask.


johnnygoodman, thanks for the explanation.

"Word recently came to us that the Hybrid is now coded under E1399 which is insurance for "misc" and by extension "do not pay". This means that while Teleflex works it out, companies like Apria and BillMyInsurance.com can not receive reimbursement for the mask and will not put it out."



SelfSeeker

[Snoredog]

I think if we search back through the very first few posts on this interface when it was first discussed here you'll see how excited all the DME's were with how much money they could possibly make off this interface with the coding the way it was done by the mfg.

I guess we now see the results of all that excitement, they stopped paying for it altogether.

Get a mask that comes complete with extra cushions and pillows then when insurance is involved you pull the items out and bill insurance for them individually inflating costs along the way.

I'm no big fan of insurance or DME's for that matter but in the end the patient always loses and the fat cats make their money.

If we had a congress with any balls they would enact laws to make it illegal for an insurance company to dictate your therapy or where you could obtain such therapy and equipment. They can jack your premium rates up or cancel you based upon any preexisting condition you might have, yet you as the patient have NO rights when it comes to therapy or who you can buy from.

Apria has become so huge they can dictate what items are available in the marketplace and even what features a machine may have, I've yet to see them do ANYTHING that benefited the patient or save them any costs. Any costs they may save go right into their stockholders coffers, you will never ever see a savings from them as a patient.

[roster]

So what I am learning here? That this is our federal government causing the problem? The US Department of Health and Human Services/Centers for Medicare and Medicaid Services establishes the codes that most insurance providers use. THEY decided that the Hybrid mask is a MISC so the insurance companies are off the hook for paying for Hybrid masks?

Too much to think about tonight; gonna go watch Chris Leak on tv and go to bed.

[mattman]

To hit it closer to home, for example, it's how we get APAPs covered (When they are covered).

I thought APAPs and CPAPs used the same code.

Nah. That's another one of the popular misconceptions here I keep hammering away at.

It CAN be billed under E0601 if all else fails.
I can sum it up like this:
Consider Jet Fuel.
All Jet Fuel is gasoline.
However, all gasoline is NOT Jet Fuel. It is selling Jet Fuel short to call it just 'gasoline' but it technically IS accurate to call it that.

Here is the more long-winded answer I gave a while ago when this came up last:

I hope you don't mind - I'll copy and paste here since it's easier then typing it all out again.

There is a little bit of a very common confusion in what you are looking at and what you are asking.

As is commonly referenced, Insurance Companies do not have a specific code set up for an APAP. CPAP has a code of E0601. Insurance Companies do not as a rule cover an auto unit due to the insurance companies considering it to be a luxury/not medically neccessary.
However, since an APAP *DOES* fulfill the defination of the code E0601 it CAN legally be provided as a E0601. There is a little bit of an important distinction there. It's not that they just don't have a seperate code for the autot, it's that they have deemed it not neccessary but since it also meets the criteria for the other unit it can be billed that way if the provider wishes to do so.

The reason that distinction is important to this is the statement that you copied above:
"More sophisticated machines ... may be covered with a specific physician prescription and documented failure to respond to standard CPAP."

This statement refers to the workaround for an auto unit not having a HCPC code. There is a catch-all code - E1399. This is the code used for something that doesn't have another code. It (generally) requires going through the insurance companies Medical Review board and is MUCH more labor intensive and time consuming.
In cases where a patient has a documented failure to respond to CPAP therapy and Bi-Level doesn't seem appropriate an attempt could be made to bill an Auto unit as an E1399 and go through the review process. This could potentially result in coverage for the Auto unit and with reimbursement determined by the insurance company.

Now, all that being said... the typical reasons an insurance company might consider an auto claim would be for things like uncontrolled aerophagia, etc.
Insurance companies will almost never consider it for things like potential future weight loss (Future possibilities generally don't matter to them), desire for monitoring (Smart-Card CPAPs will do this), less future titrations (Again, future possibilities don't matter and a low percentage of people need regular re-titration).

The easiest option is to work with your doctor and your DME provider. Talk to them. It's not uncommon for a DME company to be willing to provide an Auto unit under the E0601 code. This mostly depends on what the reimbursement for your particular policy is. Sometimes they will be willing to provide it under that code and bill you a small upcharge. Some policies allow upcharging, though many do not.
Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.

I hope some of that helps.

mattman

Clear as mud now? Heh.

mattman

[neversleeps]

mattman, I want to be sure I am understanding this:

-Some DMEs use the same code for both APAP and CPAP and accept the allowable amount from the insurance company (and write off the additional cost of the APAP?)

-Some DMEs use the same code for both APAP and CPAP and then charge their clients an upcharge for the APAP (and whether or not this is upcharge is made is determined by the insurance company and not the DME?)

-Some DMEs use the misc code for APAP in hopes of getting a higher allowable amount from the insurance company (and this is legal even though an APAP fulfills the definition of code E0601?)

-The DME is not required by law to give you the exact machine specified on the prescription by the doctor

Is that correct?

[snorkleface]

Hi
I have question-when was the code changed on the hybrid mask? I ask because my brick DME has been stalling me about getting me one( I am a Medicare pay )for 3 months since Sept. Did he know this was coming maybe? I need a mask to use when my nose is closed as it was in the beginning of Sept and I had no alternative but to not use my APAP for 3 days and nights and it took weeks to recover from that. I also thought that I was supposed to get more than 2 white filters for the APAP in every 6 months- the schedule they are keeping. I also got an obviously different and obviously less effective foam filter from the company's 6 month supplier. They agreed to check into it but then cancelled the scheduled appointments to look at it and discuss it. My year will be up in March so Medicare will allow me to change and I want to find a new supplier.

Anybody ?

Thanks ---Snorkleface

[JeffH]

I got a question....what's insurance?

JeffH...one of the 47 million that is growing in this country.